Magellan Health

For Providers

Appeals Process

As part of Magellan's ongoing efforts to reduce-and eventually eliminate all paper medical records files, we encourage Iowa Plan providers to submit appeals via e-mail or fax to DSMAppeals@MagellanHealth.com or 1-888-656-2658 (fax).

A provider may file an Appeal on behalf of a Medicaid client related to a Magellan "action", with action defined as:

  • Non-authorization or limited authorization of a requested service, including the type or level of service
  • Reduction, suspension, or termination of a previously authorized service
  • Denial, in whole or in part, of payment for a service
  • Failure to provide services in a timely manner
  • Failure to act within the timeframes established for grievances or appeals
  • Failure to provide services in a timely manner

The Iowa Plan Appeal process has one level of review by Magellan that can be:

  • Expedited, with resolution in three working days of receipt of the Expedited Appeal request, or within 14 calendar working days if the enrollee requests extension or if Magellan and DHS determine it's in the best interest of the enrollee to extend the decision timeframe
  • Standard, with resolution in 14 calendar days of receipt of the written Appeal request and any associated records
    • The 14 day standard resolution timeframe may be extended an additional 14 days if the enrollee requests extension or if there is a need for additional information and Magellan determines extension is in the client's best interest.

An Appeal must be filed with Magellan with in 30 days of Magellan's written notice of Action. Magellan acknowledges the receipt of an Appeal in writing, maintains records of Appeals, and sends written notice of Appeal resolution decisions. The resolution notice includes the date and results of the Appeal resolution, information on the State Fair Hearing process, and review of the continuation of benefits option.

A provider, on behalf of an enrollee, may request a State Fair Hearing, often referred to as an Administrative Law Judge (ALJ) hearing, if dissatisfied with Magellan's Appeal resolution. The State Fair Hearing must be requested of DHS in writing within 90 days of the date of Magellan's Appeal resolution notice. Request a State Fair Hearing by contacting:

Appeals Section, Bureau of Policy Analysis
Iowa Department of Human Services
Hoover State Office Building
Des Moines, Iowa 50319

Providers must complete Magellan's Appeal process before requesting a State Fair Hearing.

Processing of State Fair Hearings is at the discretion of DHS.

A provider, on behalf of an enrollee, may present information related to an Appeal or State Fair Hearing in person or in writing and may review Magellan documents related to the Appeal/State Fair Hearing.

A provider, on behalf of an enrollee, may request that Iowa Plan benefits continue during the Appeal process, including the State Fair Hearing. Continuation of benefits applies only when changes are made to an existing authorization and when all the following apply:

  • The Appeal involves a change in an existing authorization
  • The authorization period has not expired
  • The enrollee requests continuation of benefits
  • The services are ordered by an authorized provider
  • The request is made on or before the latter of the following
    • Within 10 days of the notice date
    • Before the effective date of Magellan's proposed Action

If the Appeal resolution or State Fair Hearing decision supports the enrollee request, Magellan will pay for the services that were requested to be continued, in keeping with Iowa Plan policies. However, when continuation of benefits has been requested, if the final decision does not support the enrollee request, the enrollee may be responsible for payment. Therefore, providers must have written documentation of an enrollee's request for continuation of benefits. 

 

Return to Top

Contact Information

Important member information: Iowa Medicaid Enterprise is now managing behavioral health services for the state of Iowa. For questions regarding your services, please call 1-800-338-7909.

** To file a grievance or appeal for services provided on or before December 31, 2015, please call Magellan Healthcare at 1-800-638-8820.